Stroke

Background: This improvement activity was done within the Geriatrics/ Stroke department and aims to meet the following adopted standards: all DNACPR forms must be signed by a senior clinician and have clear documentation of the review status, if not “indefinite.’

Local problem: Incomplete DNACPR forms with lack of senior clinicians’ signature and unclear review status, which would affect clinical effectiveness of the document.

Methods: To gather baseline and post-intervention measurements, snapshot data was collected eighteen days apart to identify patients with a DNACPR in place that includes a senior clinician’s signature, and the appropriate review status based on the senior clinician’s plan.

Interventions: To implement changes, email communications were disseminated to Geriatrics/ Stroke team, and posters displayed in prominent locations around the respective hospital wards.

Results: A total of fifty patients were admitted to the Geriatrics and Stroke wards, of which thirty-four had a DNACPR form in place. Among these, 88.2% had a senior signed DNACPR form, while only 14.7% had the review status documented. Our goal was to achieve 90% of patients having a senior signature on their DNACPR forms and 45% having the appropriate review status at the end of the second cycle.

Conclusion: At the end of the second cycle, we successfully achieved our goal of ensuring that the majority of DNACPR forms had senior signatures and appropriate review status, demonstrating an effective improvement in compliance with the established standards for DNACPR documentation.

The elderly population ( cut off 65 and over, for this audit) are being increasingly prescribed direct oral anticoagulants(DOAC) for prevention of stroke in atrial fibrillation/ prevention and treatment of DVT/PE.This poses significant difficulties when stopping/ restarting these medications in the peri-operative period , due to the ever changing clinical circumstances in this period. Therefore , we performed an audit( in Glangwili Hospital, Jan-July 2024)  , using the Welsh Frailty Fracture Network guidelines as our standard and found out(during the first cycle) that around 40 percent of patients did not have their DOAC restarted on time post surgery and that poor documentation regarding the circumstances causing delay was prevalent. We intervened by providing teaching , putting up posters and trying to include the guidelines in the trust intranet. In the second cycle, there was significant improvement in the documentation of the circumstance causing delay of restart and higher number of patients with DOACs stopped in correct time in keeping with their renal functions.

Introduction:

Osteoporosis is a known consequence of stroke, associated with an increased incidence of fractures and leading to further disability. The pattern of bone loss seen in stroke patients is different from that usually seen with postmenopausal osteoporosis. It depends on the degree of paresis, gait disability, and the duration of immobilisation.

Methods:

We retrospectively analyzed data from 20 patients admitted to the stroke ward. All patients with stroke aged more than 65 years were included in the data. Patients who were less than 65 years old, non-stroke patients, and patients who passed away during admission were excluded. Results: Fall risk assessment showed 25% of patients were low risk, 35% were medium risk, and 40% were high risk. Among them, 15% of the patients had a history of osteoporosis. Only 25% of patients had osteoporosis treatment before admission. 15% had a history of vertebral/femoral fracture in the past. We calculated the FRAX score for all patients (low risk in 44%, intermediate risk in 44%, and high risk in 12%). We compared the pre- and post-admission osteoporosis treatment (25% vs. 30%).

Proposed Plan:

Check vitamin D levels for all patients admitted to the stroke ward. Conduct falls risk assessments for all patients. Calculate FRAX scores for all patients under 90 years. Provide osteoporosis treatment if a previous vertebral fracture is found incidentally, unless contraindicated. If creatinine clearance is less than 30%, refer to the fracture liaison service or ask the GP to refer.

Conclusion:

This study highlights the high prevalence of osteoporosis and fall risk among stroke patients, emphasizing the need for routine osteoporosis screening and treatment in this population. Implementing systematic assessments and appropriate interventions can potentially reduce the risk of fractures and improve the overall quality of life for stroke patients.

Introduction: Modifiable risk factors are an important part of secondary prevention of ischaemic stroke. Many of these are modifiable lifestyle choices. We identified a lack of provision of written information to patients on the stroke ward regarding modifiable lifestyle risk factors, and undertook a quality improvement project which aimed to improve provision of information - both written and verbal - via a "Stroke Passport" document to help patient understanding.

Method: Data was collected from inpatients admitted with ischaemic stroke in the stroke ward in Prince Charles Hospital (District General Hospital), Merthyr Tydfil. A self-rated questionnaire was used to collect data on patients' perceived understanding about risk factors, and the quality of verbal and written information received during their admission pre and post introduction of a “stroke passport” document, containing written information on modifiable risk factors for stroke. Patients with delirium or unable to understand were excluded. Patients were verbally consented and helped with understanding the questionnaire by a stroke specialist nurse.

Results: Baseline data was collected from 21 patients. After introduction of the “Stroke Passport” document, data was collected from 21 different patients. Patients' perceived knowledge improved from 67% to 95% following the introduction of the stroke passport, patients’ perception of receiving verbal information from staff went from 62% to 95% and patients' perception of receiving written information increased from 0% to 100%.

Conclusion: This quality improvement project demonstrated improvements in patients’ perceived knowledge of modifiable risk factors, and in perceived quality of patient education. We suggest that a “stroke passport” document to help guide patients through their stroke journey is of benefit to patient's understanding of risk factors, and standardising the provision of written patient information. Further cycles aim to improve the educational quality of the material by assessing improvement in patient knowledge.

Introduction:

The presence of ischemic cerebrovascular accident in COVID 19 patients is a complication that has stood out due to its complications, the predisposing factors are the procoagulant state derived from the infection as well as cardiovascular arrhythmic causes. Patients: Describe the frequency of cerebral ischemia and cardiac rhythm disturbances in patients admitted to the emergency room from July 2020 to January 2021 and its impact on prognosis and mortality.

Methods:

Retrospective study of 306 adults infected by SARS COV2 by antigenic or molecular test. The presence of these events was examined in a follow-up and the associated complications were described.

Results:

There was a higher frequency of COVID 19 in the Male gender 78% in relation to the Female 22%, the ROX values were higher in the survivors at 2 h 5.7 (4.6 - 6.8), in relation to the deceased 3 ,2 (2.9 - 4.2), The presence of ischemic cerebrovascular events occurred in 9 patients (2.9%), occurring in 8 of the male gender and 1 of the female gender, the average age of those who presented said complication was 72, 3 years with standard deviations of 62.9 and 81.7 respectively, 3 of them presented cardiorespiratory arrest. Arrhythmic causes were found in only 1 of the patients, the rest were cryptogenic events. None of the cerebral panangiography studies showed aneurysms or vascular malformations. The mortality of patients with cerebral ischemia was 33% (3/9). It was not possible to perform thrombolysis in any patient. Only 1 patient was a candidate for mechanical thrombectomy.

Conclusions:

The present study showed that the presence of cerebral ischemia is not so uncommon, approaching what has been published in other series and reported works. Studies with larger groups of patients are required to validate the results found here.

Objective: To evaluate the environmental impact from home visits the ESD team carry out and the implementation of electric vehicles to reduce the carbon footprint.

Methods: Travel expense data of the ESD team across the last 2 weeks of April was collected and CO2 emissions from each team member was derived. A focus group was conducted to gather the team’s stance on electric vehicles for home visits.

Results: A significant amount of CO2 is produced daily, with the total across the two weeks being close to that of a small-to-medium enterprise. Introducing an electric vehicle would help reduce the CO2 emissions, with a 62% reduction seen in week 1 if the person with the greatest emissions were to have the vehicle.

Conclusion: Although there are disadvantages, implementing an electric car into a department where multiple home visits are carried out in a day would help significantly in reducing the carbon footprint and help NHS Wales reach their environmental targets.

Background and Aims

            Many medical specialty trainees report a lack of confidence in hyperacute stroke management, contributing to inefficient patient care. We identified a lack of knowledge of our pathways, as well as difficulty managing human factors, particularly communication and teamwork. We hypothesised that the implementation of a simulation-based education programme could address these issues amongst medical specialty trainees and lead to improvements in our door-to-needle (DNT) times.

Methods

            We organised a scenario-based simulation education session for our trainees led by a multi-disciplinary faculty. We addressed the management of acute ischaemic stroke, intracerebral haemorrhage, and basilar artery occlusion, as well as thrombolysis complications. Learners were surveyed before and after each session to gauge improvements in knowledge and confidence using a Likert scale. Free text feedback was sought from both learners and faculty to identify areas for improvement. We measured the mean DNT 3 months before and after our session.

Results

            We improved both the knowledge and confidence of trainees in managing hyperacute stroke presentations and the human factors involved in a stroke pathway. We received feedback regarding the staffing of our on-call team and improving communication, including the use of lanyard cards and single point of contact devices. We also noted an improvement in our mean DNT amongst trainees who attended our training from 62mins to 34mins. Our resources were trialled in two other healthcare trusts to refine them further, before expanding the programme locally and regionally to improve training across all healthcare trusts.

Conclusions

            Simulation education is beneficial in improving knowledge and confidence in the management of hyperacute stroke and can contribute to reduced DNT.

Background and aims: Frailty is a clinical syndrome of increased vulnerability to stressors, associated with adverse outcomes after stroke, but its impact on outcomes after transient ischaemic attack (TIA) remain unclear.

Methods: Retrospective analysis of 1185 patients referred by the emergency department (ED) who attended TIA clinic with a Clinical Frailty Scale (CFS) within two weeks. Records were combined from two routinely collected databases, and prevalence of frailty was determined. Frailty was classified as CFS score >/=4. Data were collected on date of death, and hazard ratios (HR) were determined through cox proportional hazard regression, adjusted for prognostic factors.

Results:  7945 patients were referred through the ED between 01/01/2016 and 12/03/2022. 1185 patients were included. 53.5% (n=634) had frailty. Patients with frailty tended to be older (median age 81 vs 74, p<0.001) and female (53.9% vs 39.9% p<0.001). TIA was diagnosed in 28.3% (n=335), 61.2% (n=205) of whom were frail. Stroke was diagnosed in 23.1% (n=274). 46.7% of these had frailty (n=128). In TIA patients and the whole cohort (WC), frailty (TIA: HR 2.69 [95%CI 1.23-5.87, p=0.013], WC: 2.58 [95%CI 1.64-4.08, p<0.001] ; and increasing age [HR 1.07 95% CI 1.04-1.12], were predictive of mortality. In stroke patients, only increasing age was predictive of death, (HR 1.11 [95%CI 1.04-1.19, p=0.003]).

Conclusions: Frailty is common in TIA and is predictive of mortality. Studies are required to investigate the effects of frailty on other outcomes after TIA, including: quality of life; progression to stroke; and how frailty impacts rehabilitation.

Introduction

Diagnosis of Transient Ischaemic Attack [TIA] is important to minimise risk of future strokes. This retrospective descriptive study aimed to describe frequency of alternative diagnoses in a busy inner-city neurovascular clinic and evaluate processes of assessment and investigations of ‘true’ TIA patients.

Methods

Data was obtained over a 2-year period [2019-2020] for all new patients assessed in a busy consultant-provided daily week-day neurovascular service that serves a million multi-ethnic, population. Data collected included socio-demographic details, final clinical diagnoses, and process measures including speed of assessment and rate of neurological and cardiological investigations.

Results

Of 1764 patients, 39.3% [694] were diagnosed as TIA; 60.7% [1070] had 40 distinct differential diagnoses. Top ten diagnoses included migraine including ocular migraine [9.5%], Syncope [5.5%], Local Eye conditions (non-neurological)[5.3%], non-cervical radiculopathy [4.0%], Benign Paroxysmal Positional Vertigo [4.0%], Previous/Incidental Stroke [3.7%], Transient Global Amnesia [2.4%], Orthostatic Hypotension [1.8%], Non-migraine Headache syndromes [1.6%], Cervical Neuropathy [1.3%]. 10.9%[193] had no organic pathological diagnosis. For 694 TIA patients, 100% had neuroimaging [CT/MRI] and 98% had carotid dopplers on or before day of clinic. Non-urgent cardiovascular investigations performed included echocardiogram [83%], Holter monitoring [75%] and bubble echocardiogram [5%].

Discussion

This large survey has described the frequency of TIA and alternative diagnoses in a dedicated neurovascular service. The study highlights the importance of accurate diagnosis of TIA by experienced clinicians for appropriate secondary prevention. We also described the efficiency, and speed of assessment and proportion of investigations undertaken in these patients. This study provides valuable information to clinicians, researchers and commissioners of stroke services in future.

Introduction

Diagnosis of Transient Ischaemic Attack [TIA] is important to minimise risk of future strokes. This retrospective descriptive study aimed to evaluate sociodemographic and risk factor differences between TIA and TIA ‘mimics’ in patients presenting to an inner-city neurovascular clinic.

Methods

Data was obtained over a 2-year period [2019-2020] for all new patients assessed in a consultant-provided daily week-day neurovascular service that serves a million multi-ethnic, population. Data collected included socio-demographic details, clinical risk factors, source of referral and final clinical diagnoses.

Results

Of 1764 patients, 39% [694] were diagnosed as TIA; 61% [1070] were TIA mimics with 40 distinct differential diagnoses. Compared to TIA mimics, TIA patients were older [mean (SD): 69.3(13.8) vs 59.7(16.1), p<0.001]; higher prevalence of TIA mimics in females vs males [66%vs54%; p<0.001]. There were proportionately more patients with TIA mimics from Black and minority ethnic groups (401/610:66%) compared whites (669/1154:58%) [p=0.034]. Compared to TIA mimics, TIA patients had higher prevalence of hypertension [56%vs40%, p<0.001], Diabetes [22%vs14%, p<0.001], Atrial Fibrillation [10%vs4%, p<0.001], Chronic Heart Disease [18%vs9%, p<0.001] and moderate to severe carotid stenosis [5%vs0.4%, p<0.001]. Prevalence of other risk factors in TIA patients included Patent Foramen Ovale [1.4%], Cardiolipin Antibodies [3.2%], and Thrombophilia [2.3%]. 14% of TIA patients had no identifiable risk factors.

Discussion

This large survey has described socio-demographic [age, gender and ethnicity] differences and prevalence of risk factors between TIA patients and TIA mimics. These differences may be useful in terms accurate diagnosis of TIA by experienced clinicians. This study provides valuable information for clinicians and researchers of stroke services in future.